Why some Women want to
become Men (and vice versa)

Gender identity
is the sense of belonging that one feels for a particular sex, not
only biologically but also psychologically and socially. This is
independent of one's biological sex which is simply decided on the
basis of the organs between the legs.

They say
"Congratulations! It's a girl!" or "It's a boy!" Often these are the
first words uttered when a baby is born. This utterance is based on
the genitals visible between the newborn's legs.

From then onwards the infant's fate is sealed and his or her
training starts in earnest. A boy is given toys like guns, cars,
tanks and construction kits. Girls are given dolls, kitchen sets and
sewing kits. Society even decides which color the baby will wear -
blue for a boy and pink for a girl.

This gender-related difference continues throughout a child's
upbringing, eventually resulting in an adult who has been trained to
behave in a strictly feminine or masculine manner. Anyone who
doesn't conform is labeled a weirdo.

However, whereas a child's sex is simply decided on the basis of
the organs between the legs, its gender identity
(self-identification as male or female) is decided by several
complex factors which have still not been fully understood by the
medical profession. This is what transsexualism is all about.

Gender identity is the sense of belonging that one feels for a
particular sex, not only biologically but also psychologically and
socially. It is an extremely subjective entity, which is independent
of one's biological sex.

WHAT IS
TRANSSEXUALISM ?

Quite apart from the biological sex that we are born under
(determined by the genitals between the legs ), all of us possess a
gender identity.

Transsexualism is a form of gender identity disorder (gender
dysphoria ) in which a person with a normal particular anatomical
sexual differentiation is convinced that he or she is actually a
member of the opposite sex. This conviction which is accompanied by
a profound hatred for the individual's own sexual characteristics,
is absolute, overwhelming and unalterable.

Classification of gender identity
disorders

TOTAL

TranssexualismTransvestophilia (cross-dressing for
erotic arousal)

PARTIAL UNLIMITED

Gynemimesis / Andromimesis Transvestism(desire to live
as a member of the opposite sex)

PARTIAL LIMITED

HomosexualityBisexualismLesbianism

Transsexualism can be defined as an
incongruence between the biological sex and gender-identity and it
is the most extreme form of gender dysphoria. (vide table)

In-order to label a person as a transsexual the following
criteria need to be satisfied :

The person must experience a sense of discomfort and
inappropriateness about his/ her anatomic sex.

The person must have a desire to be rid of his/her own
genitals and to live as a member of the opposite sex.

The disturbance needs to have been continuous for at least 2
years and not limited only to periods of stress.

There must not be any genetic abnormality or congenital sex
hormone disorders.

There should be an absence of coexistent mental disorder such
as schizophrenia.

ETIOLOGY

The exact etiology of transsexualism remains largely
hypothetical. Gender identity is very intimately interwoven with the
self in all human beings. This makes scientific and logical analysis
extremely difficult. Earlier it was thought that transsexualism was
a result of the effect of sex-hormone exposure (or lack of it) on
the fetal brain. Though this was proved to a large extent to be true
in experimental animals, further studies in humans born with
abnormal hormones have disproved this hypothesis.

Some psychiatrists view transsexualism as a form of delusional
psychosis. This resulted in the treatment of some transsexuals with
antipsychotic medications and electric shock therapy - but to no
avail.

Yet another school of thought believes that gender identity
development is a learning process that is superimposed on an
undifferentiated gender matrix-i.e. gender identity develops as the
result of "imprinting" and "conditioning" processes. Thus,
transsexualism is viewed as a disorder resulting from improper
learning and conditioning.

Some other studies have shown that transsexuals have a brain
structure which is neuroanatomically different from what is expected
of their biological sex. There is a particular area in the brain
which is essential for sexual behavior. This area is known as the
BSTC (bed nucleus of the stria terminals - central subdivision). A
female type of BSTC was found in male transsexuals in a pioneering
study conducted in the Netherlands.

Transsexualism is definitely not a mere whim on
the part of the affected person. It seems to be the end result
of a combination of abnormal neuroanatomy, superimposed on
which are psychological, environmental & probably hormonal
factors

Some studies have shown that mothers of female-to-male
transsexuals lack a cohesive self and possess an opposite gender
envy, which may all be communicated, albeit inadvertently, to the
growing child. This results in the child wanting to belong to the
opposite sex and identifying herself with her father.

Similarly, some psychoanalysts suggest that male-to-female
transsexualism may be the result of failure to separate the self
from the mother in early boyhood.

At the end of it all, science is still not able to clearly
explain the exact etiology of transsexualism. Transsexualism is
definitely not a mere whim on the part of the affected person.
Though ill-understood, it seems to be the end result of a
combination of abnormal neuroanatomy superimposed on which are
psychological, environmental & probably hormonal factors.

Whatever the reason be, the transsexual's plight is not a happy
one & he/she definitely needs empathy and support - not only
medical, also social.

To summarise, it may be apt to say:

That transsexualism has its foundation laid before the age of
3 years.

That the transsexual brain is probably slightly different in
its neuroanatomy.

That a myriad of psychological factors are also operational.

That rearing practices contribute to its development.

That a lot more research is needed to understand completely
the origin of transsexualism.

That, like in many other areas of clinical medicine, treatment
is often provided on empirical grounds rather than on the basis of
a full understanding of the etiology.

HISTORY

Cross-dressing and living in the role of the opposite sex have
been known to mankind for centuries. In the 17th &
18th century, it was not uncommon to find women who
joined the army or worked as sailors, pretending to be male.

History has also seen men who dressed & behaved as women.
Famous among these were the Roman emperor Calligula, King James I of
England, Lord Cornbury - Governer of New York etc.. However, in all
these cases, the gender dysphoric behavior was episodic. Today we
would probably label them as trasvestites.

The story of Chavalier D'Eon, a nobleman who served the French
King Louis XV as a diplomat in Russia is similar and slightly better
known. The year before his appointment, he spent several months in
disguise, presenting himself at the Russian court as his own
(non-existent) sister Lea. He became very popular as a woman and no
one ever doubted his self-assigned sex. Later, he served in England
where rumor had it that he was in fact a woman. He refused to settle
the question. On the royal order of Louis XV he was obliged to dress
as a woman & live a female role until his death in 1810. The
autopsy showed that he had the body of a normal male, much to the
chagrin of the pubic & the people who knew him closely.

The last 4 decades have witnessed a gradually
rising medical interest and research in this
field.

Much as it might have been desired by patients thus afflicted,
hormonal and surgical gender reassignment were impossible until the
thirties of this century. Modern documented history of
transsexualism and gender reassignment starts in 1930 with the first
recorded adult sex change operation on a Danish artist in Germany.
Einar Wegener became Lily Elbe.

After that, it was only in 1953 with the story of the surgical
gender reassignment of the American ex-GI George Jorgensen, who
became Christine Jorgensen, that transsexualism received worldwide
publicity.

The last 4 decades have witnessed a gradually rising medical
interest and research in this field. In 1966, Dr. Harry Benjamin,
who had carefully examined, treated & followed up several
transsexuals for many years in the United States of America,
published a treatise on his experience - " The Transsexual
Phenomenon".

This work contributed largely to the understanding of
transsexualism & enabled involved physicians to approach the
matter in a more scientific manner. To honor him for this great
contribution, the worldwide organisation of professionals who care
for transsexuals has been named : The Harry Benjamin International
Gender Dysphoria Association.

PREVALENCE

Transsexualism is seen all over the world. However, its
expression varies from culture to culture.

In Oman, men who live as females are known as "xaniths".
Their place in society is literally between that of men & women.
They retain male names, wear clothing which is partly male &
partly female & cut their hair medium length. They have the
right to socialise with women (unlike other men). They also have the
right to move unescorted in public (unlike women). They also have
the right to live alone, to be hired as house servants & to work
as prostitutes in a culture where prostitution is otherwise
prohibited.

Another cultural variant of cross-gender behavior is seen among
some American Indian tribes. A young adolescent boy displaying
effeminate traits is known as a "berdache". After getting
into a divine trance and receiving 'spiritual enlightenment', a
berdache begins to dress as a female & engages in sexual
relations with males or even lives as a berdache wife with a
husband.

Hijras form a kind of a social institution, a
religious cult with its own mother goddess, Bahuchara
Mata.

In India we have the "hijra" community which is a motley
group of people belonging to different religious communities. Many
of them are male-to-female transsexuals but the group also consists
of adolescent boys who have undergone early castration &
children with intersex disorders. Traditionally, all hijras undergo
amputation of the penis, scrotum & testis - a procedure
performed extremely crudely by senior established hijras. Hijras
form a kind of a social institution, a religious cult with its own
mother goddess, Bahuchara Mata.

Male-to-female transsexuals in Burma group together similarly.
They are looked upon as being possessed by a spirit of the opposite
sex. They play a special role in temples and are known to
participate in special semi-religious ceremonies.

The exact prevalence of transsexualism is difficult to assess
because only a fraction (size being dependent on the socio-cultural
ethos) of transsexuals seek therapy. However, in the USA, it is
estimated at 1 in 100,000 for male-to-female transsexuals and 1 in
400,000 for female-to-male transsexuals. In England – 1 in 30,000
and 1 in 100,000 respectively. In Sweden 1 in 37,000 and 1 in
103,000 respectively. The ratio of male-to-female and female-to-male
remains around 3:1, country notwithstanding.

MANIFESTATIONS

Most adult transsexuals confess to having experienced a hatred
for their gender right from early life - well before puberty. Many
remember puberty with abhorrence, because of the hormone-induced
changes in body characteristics which they perceived as totally
alien to their gender identity. Often, it is around the pubertal
period that most transsexuals reinforce their determination to rid
themselves of their primary & secondary characteristics.

In some cases, hatred for one's gender is seen at a very young
age. It may manifest, for example, in a young boy as a desire to
wear skirts & frocks and to play with dolls or kitchen sets.
Retrospective and prospective studies have corroborated that such
boys often grow up to be homosexuals and less often -
transsexuals.

TREATMENT

Establishing a diagnosis of transsexualism is not very simple.
Apart from a detailed clinical interview and physical examination,
the individual has to go through rigorous psychological
evaluation.

It is only after all the members of our gender team agree on the
matter, that we take up the transsexual for gender-reassignment.

The process of gender-reassignment includes medical treatment
with cross-gender hormones for a variable period of time (usually
one to one and a half years). This is followed by sex-reassignment
surgery.

CASE STUDY

Shanti (desired name Sushant) is a
23 year old female transsexual. (As a mark of our respect
& empathy for their predicament, we prefer to use pronouns
befitting their desired sex). He had a normal birth history.
His memories of his hatred of his anatomical sex (female)
dates back to his early childhood where he recalls his intense
dislike for the school uniform (a pleated dress) that he was
compelled to wear - so much so that he would wear shorts under
the dress and literally rip open the dress as soon as he
entered his home. The onset of puberty accompanied by the
development of breasts and the beginning of the menstrual
cycle saw him in great depression. It was then that he
realised that he "felt like a man trapped in a womans body".
That was also when he became firm in his resolve to find a
solution to his problem. Around the same time he realised his
affinity for female company & the fact that he was, in
fact, sexually attracted to girls. This was almost 10 years
ago and the last decade has seen him drift in and out of 2
romantic liaisons with girls. In the last 3 years or so, he
seems to have found his soulmate in a very compassionate woman
who he plans to marry as soon as his gender has been more or
less completely reassigned.

GENDER REASSIGNMENT
SURGERY

There is no hard and fast age limit for gender change operations.
However, a few guidelines apply. Generally, patients present for
surgery during late adolescence or early adulthood - an age group
where sexuality must begin to manifest itself physically and the
issue is no longer merely one of psychological and emotional
conflict with one's sexuality.

The sexual urge in this age group of transsexuals is as strong as
in those with normal sexuality. This is what causes frustration and
depression. Many patients already have a sexual partner when they
present for operation. It is important to note that transsexuals do
not usually engage in homosexual activity. They would like to change
their gender and have peno-vaginal intercourse.

Exceptionally, operation is undertaken in older patients. This is
usually in those who were unaware of the concept of gender
reassignment surgery. When they come to know that it is possible,
they turn up for operation. If they fulfill other criteria and
psychiatrists give the go ahead, they are taken up for
operation.

PRE-REQUISITES TO
BE CONSIDERED

Physically, the patient should be fit to undergo the rigors of
anesthesia and surgery. Not only that, the patient wants to have sex
after operation. Infirm patients can't have sex and must not be
operated upon.

Mental health is important too. Normally three
psychologists/psychiatrists need to certify that the patient has
true and pure transsexualism and that he or she is strongly
motivated not only to undergo surgery but also for the long journey
to total rehabilitation. The patient should also be stable and must
not be the type who might change his/her mind after operation,
because the operation is irreversible.

The patient should also understand that we are dealing here with
a situation that is not usual and is predominantly psycho-emotional
rather than physical. Operation is only one of the steps. The
patient should be prepared for the other sociological issues too.
Miracles should neither be promised nor expected. Patients with an
overlay of other psychiatric disturbances mustn't be offered
operation.

Weight and height are generally not of especial consequence.
There have been very tall, hefty men who have wanted to become women
and similarly very short, diminutive women who have wanted to become
men. As we have seen earlier, the primary problem is in the mind. If
a 6 foot tall, muscular man thinks he is a woman and wants a vagina
and breasts, it is our job to give it to him - provided other
criteria are fulfilled.

RISKS AND
COMPLICATIONS

Risks and complications are the same as in any other situation
where anesthesia and operation are involved.

Additionally, in male-to-female operations we may, for instance,
sometimes have the complication of vaginal stenosis. Occasionally,
for anatomic reasons such as a narrow pelvis, the vagina is short
and narrow. The labial flaps may sometimes require secondary
revision for cosmetic purposes. There may be urethral stenosis in
some patients.

In female-to-male operations, there may be problems with the
flaps, such as necrosis or contracture. There may be a malfunction
of prostheses. Urinary fistulae can occur. Sensations on flaps may
be inappropriate and patients may be less than satisfied with the
cosmetic appearance etc..

SUCCESS RATES OF
SURGERY

Success rates are difficult to define because a number of
parameters are involved.

Male-to-female conversions are generally more successful in terms
of both operative technique and patient satisfaction in cosmetic
appearance and sexual rehabilitation. Hospital stay is also quite
short and the operation is one-stage. Dissatisfaction may creep in
later because of disappointment with body hair, breast development
or voice change.

Female-to-male operations are less than optimal in technique
because the ideal phalloplasty has not yet been described (The Chief
Medical Consultant of this site is currently working on a new
technique). Most phalloplasties are multi-stage and cause physical,
temporal and economic inconvenience to the patient. Also, many
phalloplastic penises are incapable of either sexual sensation or
performance (we hope to be able to make both possible). Also,
ultimate success is a function not only of operative results but
also of social acceptance, partner availability and total
rehabilitation.

OPERATION REVERSAL
?

In case the patient changes his/ her mind and requests a
reversal:

A male-to-female operation-failed patient can never become
male again because both his penis and testes are removed.

If a female-to-male operation fails, the patient may or may
not be able to use the vagina depending on the phalloplasty
technique used. In some techniques, the vagina is used for
neo-urethra construction.

But since these patients never had `normal' sexual functioning
even before operation, the question of returning to one does not
arise. There is just no way these people want to use their
biological genitalia. This must be the first thing ascertained
before operation.